Alternative therapies have emerged out of the public's dissatisfaction with the limitations of conventional treatments. The conventional medical system has boxed itself into only diagnosing and treating disease rather then focusing on prevention. Although attempts to correct public perception have been made with a push for early diagnosis of disease, conventional medicine is still unable to be of help to healthy people who are just looking for ways to stay healthy.

What conventional medicine considers prevention- PAP smears, mammographies, colonoscopies, cardiac stress tests-are actually methods of diagnosing diseases at early stages. Not one of these methods actually prevents diseases from occurring. Desperately aware of the need to prevent disease, the public has been searching for different avenues of true prevention. As our population lives longer and healthier lives, deferring the aging process has become a must for many people. In fact, a whole booming industry has developed in an attempt to satisfy this urgent need to stay young and healthy. Menopause and its attendant hormone imbalances have provided an enormous amount of fuel for the alternative health industry. Billions of dollars are spent every year by women in search of alternative help for symptoms of hormone imbalance, and millions of dollars are spent by the alternative industry in the development and promotion of alternative treatments.

While the alternative trend is booming, it behooves conventional doctors and patients to become vigilant, well informed and careful in making safe and effective choices in this new area. In the past many of my patients have come to me with questions on alternative therapies. As a conventional physician I had limited access to the alternative world, and I had to do my own research. In the end, I became somewhat of an expert, I've begun to use alterative therapies in my practice- with varying results. This chapter offers an overview of the alternative medicine world I've been sharing with my patients and have had some success with.

But before you try any of these remedies, I strongly suggest you to seek professional advise. Do not follow advice given by sales people in health food stores, or on-line advertising by marketers for the particular product they are selling. Do not fall prey to advertised specials for cure-all medications, you don't know what is in them, you don't know what their effects will be. Find a physician interested in alternative therapies, go to a health care provider with experience and get the most knowledgeable help available. Even if these products are available over-the-counter, they may not be as safe as you think they are. Remember, there is only one of you and every time you take a supplement or medication, you are affecting your body's balance.

Regulation of Supplements and Herbs Most supplements and herbs are not regulated by the Food and Drug Administration (F.D.A.). This is the single most important piece of information you must be aware of when making alternative therapy choices.

The Food and Drug Administration is the federal regulatory body that approves medication for usage by the public. The only medications approved by this agency are pharmaceuticals, medications with unique chemical formulations, patented and having undergone rigorous and expensive processes of testing for function and safety.

F.D.A. approval is a large part of the expense of bringing patented medications to market. Having obtained this approval drug companies can make certain claims that serve to differentiate between medications and allow them to charge higher prices for their products. Because the F.D.A. approval process is tedious and expensive, only pharmaceutical companies with unlimited funds can undergo it.

As an aside, even F.D.A. approval does not guarantee safety. F.D.A. approved medications are often taken off the market in a hurry when they prove dangerous to users. A few recent examples are: Duract- anti-inflammatory medication taken off the market because it caused liver failure, Rezulin- a drug used to treat type 2 diabetes that caused liver toxicity, Seldane- an antihistamine with cardiac and other untoward side-effects.

The F.D.A. does not evaluate the function and safety, or supervise the manufacturing of alternative therapies, herbs and supplements. As these are natural, unpatentable substances, there is no large company who serves to make a great deal of money from the F.D.A.'s approval and the public's wide usage of the products. Therefore, most alternative therapies, herbs, and supplements do not undergo the costly approval process from the FDA. Again, this does not mean that they are not safe or effective. Nonetheless this situation leaves us, the public in a precarious position. Whenever you go to a health food store, you are buying on faith.

The information on the label is vague, contents are somewhat questionable and I am sure you noticed, indications for use are invariably missing. You may never know exactly what is in the pill you're taking. And that's a scary thought. We live in a society where the best marketer, the company that spends the most money on advertising, gets their product sold.

So how do you choose which supplement or herb to take?

Who is the product manufacturer? When I started researching alternative treatments for symptoms of hormone imbalance, I learned something few people know. There are very few manufacturers of raw supplements, vitamins and herbs. The enormous variety of brands that fill the shelves of our health food stores, are often the same product packaged by different companies.

Let me explain a little further.

Let's take Dong Quai- an herbal supplement that presumably improves hot flashes. Dong Quai can be found in stores under as many as twenty different labels. Most Dong Quai is produced by a handful of manufacturing companies that package the raw Dong Quai under different labels. It is impossible to determine who the manufacturer is, and which product is better. Anybody can contract with a manufacturer, then get a packager, put their own label on a supplement, and then sell it to the public. It's that simple. But it leaves the public in an uncomfortable position. On the other hand, the industry has recognized the need for laboratory tested brands, and a few manufacturers with long standing solid track records have established themselves in the market. Their products are standardized. For the consumer this is an important fact. Standardized, means, that the dosing is the same from batch to batch of supplement. For instance- St. John's wort made by Pharmanex has the same amount of active ingredients in every bottle of St. John's wort bought under the Pharmanex label. Since there is no regulatory agency that requires standardization of dosing, the manufacturer decides whether to provide internal testing and quality control for their products.

I advise you to stick with standardized labeled products for your own safety. Some examples of standardized labeled products include: Pharmanex, Nature's Bounty, Solgar, and Twin Labs.

Bioavailability Assuming that you have chosen a reliable brand with a proven track record there still are no guarantees the therapy will work for you. A potential stumbling block to benefiting the most from your chosen herb, vitamin or supplement, is bioavailability.

A big word with big implications- bioavailability represents the amount of active ingredient in the medication or supplement that gets into your blood stream and can be effectively used by your body. You could take pounds of supplements without visible improvement in your condition simply because your body is unable to extract its beneficial ingredients. A perfect example is yam in its natural forms. Although yams contain progesterone- the hormone our body needs- eating yams will never give you that progesterone. That is because our bodies cannot make yams bioavailable, meaning it cannot extract the progesterone from them. How the supplement gets into your system, what the body does with it once it's in your blood stream, how much of it gets to your cells and how they use it, are only parts of the bioavailability story. When medications are tested for effectiveness, the most important marker is their bioavailability. With supplements and food substances, that are not under FDA scrutiny, bioavailability is not even addressed.

Another example of variable bioavailability is calcium. Calcium is essential to good bone structure. But taking calcium supplements does not insure that more calcium gets into our system, let alone to our bone cells or into our bones. Let's follow the path of a calcium pill you take in the evening, three hours after your last meal. Your stomach is empty and the pill gets broken down into tiny components by gastric juices. If the components are small enough, the calcium supplement you took gets absorbed into your blood stream. If it isn't small enough, it goes through the stomach and into the intestine and out the other end- no calcium supplement for your body. If it gets absorbed into your blood stream it has a good chance of getting to your bone cells. But once there, there is no guarantee that the cells that need the calcium have the enzymes, substrates, and all other necessary environmental elements, to absorb the calcium molecules and use them to make strong bones.

The path I use to describe the fate of calcium in your body is similar to any other food or medication you take. There are lots of great supplements available with incredible potential benefits. The reason they don't live up to their promises is because they are not bioavailable. This is one of the key reasons many supplements just don't work. In an attempt to improve bioavailability, many manufacturers advise taking their supplements on an empty stomach. The reason behind this method of administration is that hypothetically, an empty stomach will be more inclined to digest and absorb a supplement than if mixed with other foods or medications. I stress hypothetically, because there are no studies to substantiate the bioavailability of most supplements on the market today.

Other methods of administration (besides pills and tablets) have better rates of absorption and bioavailability. Pharmaceutical companies have conducted numerous studies that reinforce the increased bioavailability of creams and gels. The reason is primarily that skin is a more predictable absorbent, it is the largest organ in the human body and the blood flow to the skin is high in warm areas, like chest, inner thighs, arms, and pulse points (wrists, ankles, armpits, groin).

From a clinical standpoint, degree of bioavailability of a substance is directly proportional to its expected effect. If you are taking a pill to get rid of a headache and the headache is gone in thirty minutes to an hour after you took the pill, clinically speaking, the pill was bioavailable enough to be effective. When we discuss the bioavailability of natural hormones or supplements we are referring to subjectively measurable effects (like elimination of hot flashes, or night sweats for instance).

Professional Advice When taking herbal supplements, the type of professional advice you get is critical.

Because herbs and supplements are not prescription medications you can acquire them without any supervision. That may feel like a freeing experience, but the risk of getting into trouble and not even knowing it is very high. I am blessed with a group of very intelligent and proactive patients. Whenever I ask them how they make their choices of supplements, the answers astound me- friends, TV ads, women's magazines, and the Internet. Missing from this list is the qualified expert. Mostly because there is a paucity of experts. When you walk into a health food store, the salesperson behind the counter will most likely try to sell you the special of the day. When you go to an alternative doctor or naturopath, he/she will try to sell you their own products. Experts in alternative medicine don't know much about disease processes and conventional doctors know little about herbs and supplements.

The following pages address alternative therapies for symptoms of hormone imbalance at a generic level. When it comes to brands, choose tried and true. The brands on the market the longest, laboratory tested and found in reputable stores. Do not go for the bargains, they usually are of poor quality and a waste of money in the long run.

Until we have more integrative doctors, experts in alternative options who will not miss disease and who are willing to correctly combine therapeutic options, the onus is on you to do some research, gather all the information you can to help you and bring it to a physician willing to listen and work with you in the area of alternative treatments. Bloating Herbal diuretics work almost as well as their prescription version. Their action is milder then their pharmaceutical counterparts and do not deplete your body's potassium as rapidly. Stomach discomfort does on occasion limit their use.

Chickweed, nettle, and uva ursi are most commonly recommended for relief of water retention. The information on these herbs is scant and not based on data obtained from scientifically qualified studies. Their credibility comes from hundreds of years of use in herbal medicine practices. They can be purchased in capsules, powders, teas, and tablets. The dosing as well as the quality of the products depends on the particular brand. Try a standardized laboratory tested brand and if obtain no relief after two or three uses, discontinue and try another brand or another remedy. My personal practice experience has been poor with regard to the use of diuretic herbs. I do prefer a conventional diuretic because of the consistency in action and the F.D.A. standardization it carries.

Uva-Ursi- Beyond its acceptability as a diuretic, this herb has application as a urinary tract disinfectant, alleged to support the health of the urinary tract and kidneys. Clinical studies are limited and as such provide little information on the herb's effectiveness. Although widely used as a diuretic, no clinical studies exist with reference to its function as a diuretic.

Nettle- A dual action herb. Some of the herbal supplement distributors recommend nettle as a diuretic while others suggest it be used for relief of allergies. No clinical references or scientific studies are published to date to substantiate either role for this herb.

POST-PARTUM DEPRESSION, DEPRESSION, AND MOOD SWINGS While there is no question that relaxation techniques, enough sleep and a diet low in processed, chemical filled foods, will help improve anyone's mood, there are a few herbal and other types of supplements which may help as well. Their value is that they are lower in cost and have fewer side-effects than conventional anti-depressants. The comparison of dependency rates in usage of conventional versus alternative anti-depressants has not been established through any long term clinical studies.

St. John's Wort

Extracts of this herb have long been used in folk medicine. In Germany, St. John's wort is licensed for the treatment of anxiety, depression and sleep disorders. The extracts that make up this herbal remedy contain many different chemical classes, so the "active agent" is a matter of uncertainty. The use of St. John's wort extracts to treat mild to moderate depression is supported by over twenty alternative clinical studies. Its efficacy is comparable to standard tricyclic antidepressants but the severity of side-effects is lower for St. John's wort. Therapeutic response should develop in days to weeks with minimum treatment duration of four to six weeks in any reported study. Side-effects include fatigue, allergic reactions and stomach discomfort.

SAMe An amino acid supplement, S-adenosylmethionine (ah-de-no-sil meh-thio-neene) has been used by some psychiatrists in the treatment of depression, for the past 20 years, predominantly in Europe. Substantial claims for the use of SAMe in the treatment of osteoarthritis, liver disease, fibromyalgia, and chronic pain have been made in books published in the popular literature in the past two years. Because it is a supplement and does not require prescription it is easily accessible. Its alleged versatility made it very popular when information on it was first published. Unfortunately, while SAMe may have value in the treatment of mild depression, it fell short of the mark when patients in my practice tried it on their own. The problem with SAMe is that dosing is critical and unless taken under the supervision of a knowledgeable physician, results are usually poor, the patient becomes discouraged and discontinues it. The over-the-counter recommended dosage for SAMe is much less than the therapeutic dosage needed for optimum results, making it potentially dangerous for a patient to self-medicate and reach the desired outcome.

When using alternative anti-depressants in my practice, the results I find are mixed. The cost of the medication often becomes prohibitive at the dose levels patients require to feel significant improvement in their symptoms. As a consequence the use of conventional medications, covered by insurance, becomes more attractive. On the other hand, some patients have reported significant relief of temporary depressive episodes and did take SAMe or St. John's wort for periods of a few months. With St. John's wort the problem with allergies significantly limits its use. I selectively recommend using either SAMe or St. John's wort for mild depressive episodes, while balancing hormone levels, for short periods of time (no longer than six months). The side-effects of these alternative anti-depressants are far less than those of prescription medications and the addictive tendencies appear to be lower. HOT FLASHES In Chapter 4, we uncovered that conventional medicine has very little to offer with regard to the treatment of hot flashes. This is not the case with alternative therapies. For approximately a year before natural hormones became the best option for treatment of hot flashes, herbal supplements seemed the only viable possibility in my practice.

Vitex, Black Cohosh and Oil of Evening Primrose are the most popular herbal supplements in this category. Over the years I have found that some women swear by these supplements, while others find them totally useless. You may find these herbs to work for a while, especially in younger women with occasional hot flashes. When hot flashes increase in frequency and other symptoms of hormone depletion compound the picture, herbal remedies rapidly become less effective.

Vitex (also known as chasteberry, monk's pepper, agnus castus, agni casti fructus, chaste tree) has more than one active ingredient, including flavonoids and iridoids. Some clinical data exist to support the use of Vitex extract in infertility associated with corpus luteum insufficiency, PMS and PMTS (premenstrual tension syndromes), acne especially associated with PMS, amenorrhea ( lack of periods), polymenorrhea ( too frequent periods) and mastodynia ( breast discomfort). Most of the research on this product so far has been in Germany; results have led to the belief that Vitex acts on the anterior pituitary decreasing prolactin levels and increasing progesterone levels. Women with PMS have high levels of prolactin and lower-than- normal levels of progesterone. Vitex does improve the hormone balance and thus may relieve the symptoms. Although its use is wide-spread, the side-effects are quite limiting. They include diarrhea, weight gain, rashes, nausea and headaches. Vitex should not be used in combination with hormone treatment, birth control pills, or while breast feeding.

Black Cohosh- Its primary application is to help ease the physical and mental changes associated with perimenopause and menopause- hot flashes, headaches, irritability, depression. Black cohosh has also been used to symptomatically treat hormonal deficits arising from ovariectomy and hysterectomy in younger women. While some clinical studies do exist to support the primary application of Black cohosh for the treatment of perimenopausal symptoms such as hot flashes, headaches, palpitations, ringing in the ears, sleep disturbances and mood disorders, its mode of action is poorly understood or described. Treatment requires at least eight weeks to alleviate symptoms. Clinical studies have ranged from eight weeks to six months, the results are equivocal at best. Side-effects include stomach irritation, nausea, and dizziness. Although the supportive literature on black cohosh states that it can be used in conjunction with estrogen supplementation without side-effects, I would not recommend it. Once on natural hormone supplementation, there is no reason to take additional supplements.

Oil of Evening Primrose- Classified as an essential nutrient, evening primrose contains essential fatty acids ( EFAs) particularly omega-6 and gamma linoleic acid ( GLA). Used for skin disorders and hyperactivity in children, evening primrose has found a great niche in women's health: PMS, breast health, pregnancy and lactation. A study in Lancet in 1985 compared the effect of oil of evening primrose and two conventional medications on breast pain. Improvement of symptoms was not significant with oil of evening primrose, but there were fewer side-effects than with conventional medications. Although often prescribed for symptoms of menopause, oil of evening primrose alone, is of no value in the treatment of hot flashes. I must also caution you that seizures have been reported in patients on antipsychotic medications who took oil of evening primrose with the medication (Internal Medicine- May 2001- Alternatives Ease Some Menstrual Symptoms).

A word of caution when it comes to herbal supplements and soy derivatives Black cohosh, isoflavones, ipriflavones, soy derivatives, soy milk, soy nuts, Vitex and Dong Quai are phytoestrogens. Their chemical make-up resembles human estrogen molecules closely enough for the body to misread them as estrogens. For that reason they do work on alleviating some of the symptoms of estrogen deficiency. But they are not estrogens and they do not offer the beneficial effects we obtain from estriol, estrone or estradiol- natural estrogens. There are no research data to substantiate beneficial estrogen-like effects on the heart, bones or brain.

Thus, while we think we are helping our situation by reducing the discomfort associated with the symptoms we experience, we may be doing ourselves a disservice. Heart disease and osteoporosis progress unimpeded when all we take are phytoestrogens.

A commonly used proof of the positive effects of soy is rooted in the Japanese culture. Japanese women are known to suffer few if any side effects of menopause. Japanese diet is rich in soy products- tofu, soy milk and nuts. The connection between soy and the lack of menopause symptoms was thus made. However, no scientific data have substantiated this theory. Maybe it is genetics. Maybe Japanese women are genetically programmed to suffer fewer effects of hormone imbalance.

Until we have definite proof of soy's benefit to women, I do not recommend soy derived supplements to my patients. I emphatically advise against isoflavones, ipriflavones, genistein- all found in capsule, powders and gelcap forms. This does not mean you should stay away from soy milk, tofu or other soy products. Soy - in natural form and in moderation- is an excellent source of protein and should be used as such.

INSOMNIA AND SLEEP DISORDERS Long before we had sleeping pills, herbal remedies were routinely used in the treatment of sleep disorders. Herbs are currently used for the treatment of insomnia not only in alternative practices, but some conventional ones as well.

Valerian-Also known as vandalroot and garden heliotrope, finds its primary application in the treatment of insomnia, nervousness and improvement of sleep quality. A number of clinical trials have shown valerian to be an effective sedative for many people, with an efficacy comparable to standard prescription medications such as benzodiazepines (Valium). Valerian extracts generally display fewer side-effects than standard sleep medications, are better tolerated, and present a lower risk of dependency. Chronic use may result in headache, excitability, insomnia and irregularities in heart beat.

Kava Kava- Used as a muscle relaxant and anti-anxiety herb, Kava has a significant sedative component. It has been used safely in Polynesian society for centuries. In European phytomedicine it is recommended for the treatment of mild insomnia, anxiety and muscular tension. Some clinical studies have demonstrated that Kava Kava induces a state of relaxation and calm without interfering with cognition, memory, or alertness. Side-effects are rare and associated with excess use. They include skin rashes and a syndrome- a collection of symptoms- similar to Parkinsonism. After discontinuation of the medication, the symptoms eventually disappear.

Melatonin- A normal secretion of the pineal gland, melatonin has captured the public's attention because of its alleged effects on mood, sleep and jet-lag. Promoted as a miracle, this supplement was the number one over the counter sleeping pill a couple of years ago. Unfortunately its track record has not been so glorious. Study after study has failed to substantiate the claims it made as the ultimate natural sleeping remedy. Scientific and public health concerns over the dissonance between its wide use and evidence of benefit led to the convening of a workshop on melatonin by the National Institutes of Health in 1996. The workshop's general conclusions were that, while there have been no medical catastrophes caused by melatonin, no long term positive effects have been identified either. It might be of short term benefit for insomniacs or travelers crossing multiple time-zones, but that seems to be an individual opinion rather than a scientifically supported fact.

HEADACHES AND MIGRAINES Alternative treatments for headaches include acupuncture, yoga, relaxation, massages and aromatherapy. Many patients shy away from herbal remedies because of potential allergies that often worsen the headaches. A few herbals have gained some acceptance in the treatment of headaches.

Dong Quai- Although its main application is in the treatment of menstrual disorders and menstrual cramps, Dong Quai is often used to treat headaches. While there are practically no clinical studies on this herb, animal and in vitro studies suggest that Dong Quai may be useful as an anti-inflammatory, smooth muscle relaxant, analgesic, and mild sedative.

Feverfew- is used in migraine prophylaxis as well as treatment of migraines. The current consensus is that feverfew may work prophylactically to prevent migraines, and that emphasis should be placed on the use of high quality preparations with detectable and consistent levels of its key components (parthenolide levels of 0.2% to 0.9%). While clinical investigations have shown mixed results, two studies indicate that feverfew treatment results in a reduction in frequency of migraines and milder migraines in pre-treated individuals. Feverfew is also used in combination with vitamin B12 and Magnesium with some decrease in frequency of headaches. Side effects include stomach problems, diarrhea, allergic reactions to the fresh leaf when ingested, flatulence and unpleasant taste.

LOSS OF SEX DRIVE AND LOSS OF LIBIDO Alternative medicine comes up just as short as conventional medicine in the treatment of loss of sex drive experienced by most women as a result of hormone imbalance. Information we have is anecdotal. It relates to the use of Belladonna, an herb with central nervous system action. It induces dilation of the pupils and was used by courtesans in the 18th century in Italy to attract men. I have never heard it used in the 21st century for the improvement of sex drive.

DHEA Dihydroepiandrosterone (Di-hidro-epi-andro-sterone) is a precursor of Estrone, testosterone and estradiol. It is available over the counter and used as androgen replacement for women with loss of sex drive. The most popular products are Natrol and Just Right. Data on the efficacy of DHEA are variable. Improvement in sexual function may occur but side-effects of increased hair growth and acne limit its use.

Adapted from The Hormone Solution by Erika Schwartz, M.D. Buy the complete book for $13.95 including postage.